J Korean Orthop Assoc.  2009 Dec;44(6):651-660. 10.4055/jkoa.2009.44.6.651.

The Treatment of Nonunion of the Scaphoid with a Horse-Shoe Bone Graft and Fixation with Two Screws

• Kang HJ
• Park H
• Hahn SB

• KMID: 2186292
• DOI: http://doi.org/10.4055/jkoa.2009.44.6.651

Abstract

PURPOSE
Three dimensional anatomical reconstruction of an old scaphoid nonunion injury with a humpback deformity is not an easy procedure. The single interpositional bone graft technique has its limitation for accurate anatomic reconstruction. We report here on the effect of a cortical interpositional horse-shoe graft using two screws and a volar cancellous chip bone graft for the treatment of scaphoid nonunion with a humpback deformity or a miss-match fracture surface in scaphoid nonunion.
MATERIALS AND METHODS
We retrospectively reviewed nineteen patients who were treated for scaphoid nonunion using a cancellous chip bone graft and a cortical interpositional horse-shoe graft with 2 screws (a Herbert's screw and a mini screw). The mean follow up period was 24 months (range: 14-36 months). The mean age was 30.5 years (range: 17-52 years) and 18 patients were male and 1 patient was female. The mean period between injury and operation was 6.7 years (range: 1 to 30 years). The nonunion sites were located in the waist in 15 wrists and in the distal third in 4 wrists. The volar approach was used in 18 cases and the dorsal approach was used in 1 case. In 2 cases, one additional kirschner's wire was used due to the instability of fixation. The clinical results were assessed by the criteria of Maudesley and Chen at the last follow-up.
RESULTS
Bony union was obtained in 18 (95%) cases. The average time for union was 13 weeks. There were improvements in the scapholunate angle (from 65.2 degrees to 49.5 degrees) and the intrascaphoid angle (from 43.5 degrees to 29.6 degrees). There are 3 cases with excellent results, 10 cases with good results and 6 cases with fair results. There was one complication. In 1 case, a nonunion gap was seen at 7 months after operation, but there were no clinical symptoms.
CONCLUSION
A cortical interpositional horse-shoe graft using two screws and a cancellous chip bone graft for treating scaphoid nonunion with a humpback deformity or a large defect seems to be an encouraging procedure for regaining the normal anatomy of the scaphoid.

Keyword

Scaphoid; Nonunion; Cortical interpositional horse-shoe graft; Two screws fixation technique

MeSH Terms

Congenital Abnormalities
Female
Follow-Up Studies
Humans
Male
Retrospective Studies
Transplants
Wrist

Figure

• 

  Fig. 1 Operative method. (A) Percutaneous fixation with 2 Kirschner's wires holding alignment of scaphoid. (B) After compaction of corticocancellous bone at non-union site, horse-shoe bone graft (black arrow) was done from iliac crest. (C) For obtaining additional stability by compressive & buttress effect, oblique additional fixation with Leibinger or AO mini screw (white arrow) at proximal or distal portion of scaphoid.

• 

  Fig. 2 A 52 year-old man with pain of right wrist for 30 years. (A) Preoperative radiograph show non-union of scaphoid, sclerotic change of fracture site & traumatic arthritis of styloid process & radio-scaphoid joint. (B) Preoperative CT show sclerotic change & comminution of fracture site. (C, D) Because instability was detected on postoperative radiograph, additional fixation was done with one Kirschner's wire.

• 

  Fig. 3 A 17 year-old man with pain of left wrist for 1 year. (A, B) Nonuion of waist portion & traumatic arthritis (white arrow) of styloid process & scaphoid was seen on preoperative radiograph & CT. (C, D) Postoperative radiograph show complete union 12 weeks after surgery.

• 

  Fig. 4 A 35 year-old man with pain of right wrist for 14 years. (A, B) Nonuion of waist portion & humpback deformity was seen on preoperative radiograph & CT. (C, D) Postoperative radiograph show complete reduction & union 5 months after surgery.

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  Fig. 5 A 46 year-old man with pain of left wrist for 14 years. Postoperative radiograph show non-union gap (white arrow) 24 months after surgery.

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